Friday, July 13, 2012

His name was Girard. He had back pain. That's all I remember about him.

On July 13, many years ago, he was the very first patient I ever saw on my own.

Working
without a net for the first time is terrifying. I'd survived 4 years of
medical school, 4 years of residency, and 1 year of fellowship to get
there. This is the goal I wanted. And when it finally came it scared the
crap out of me.

There was fear in medical school,
starting classes and later starting clinicals, and even more in
residency. But in both those cases there was always a back-up system-
more senior people who actually knew what they were doing. There was
also a herd-based support system: You were with plenty of other people,
all sharing the same challenges.

But here, after 9
years of training, it was just me and Girard. Even though his case was
simple, it's pretty damn scary to realize that YOU are the attending,
and if you screw up there's no one else to blame.

I
remember another patient that day started the visit by saying "I came to
Humungous Neurology because I heard you guys are the most experienced."
My inner voice said "you probably don't want to know this is my first day."

Throughout
medical school you saw the attending physicians as omniscient giants.
Suddenly you're one of them, and realize that they don't know
everything. And you aren't a giant.

Like everything
else, after a while it becomes routine. But trying to remember that
first day still helps to keep you on your toes.

I don't
remember how many patients I saw that first day. A handful compared to
what I see now. One of them is still with me. I think I told her a few
years later she was on my first day. I even got a hospital consult, a
lady who'd obviously had a stroke. I got lost in the hospital trying to
find her room, then sat in the MRI control room to see images, terrified
at the thought that if they were normal I'd have no idea what was going
on.

I've now spent an estimated 4,650 days of seeing
patients in one place or another, with a lot more to go. But the first
one was the scariest. And hopefully always will be.

25 comments:

I've just finished medical school and so start 1st job as a junior doctor in August. Beginning to feel like any knowledge I had for Finals has all but been forgotten, and that first day will be a complete disaster.

To make matters worse the higher-up doctors also change over that day so will be having inductions, so apart from the consultants there won't be as many people on the wards as other days as well.

Just hoping no patients die that day, and I get every vein I need to get blood from.

I'm experiencing that period just prior to starting as an attending currently. I have never been as downright fearful as I am right now. I am so stressed about it I'm actually getting a little bit of conversion disorder from it! I guess it will help in my patient understanding. I know it will all work out ok, but I wanted to go say thanks for writing that. It's nice to hear that others had the same type of feelings. Love your blog too by the way, I've been reading for a couple of years now.

Actually, Officer, my favorite doc would occasionally admit he didn't know what was wrong to the patient. Loved the honesty. That didn't mean he just stopped looking and learning....he just went and read, or referred. And he ended his office practice never being sued. Food for thought. There is a "first day" for all of us.

I remember my first day as an ER attending. About an hour into my first shift I had a guy with a VFib arrest. After getting him back and sending him to the cath lab, I thought - alright I can do this.....

Pharmacy is the same way Grumpy, you spend years in internship, graduate, take your exams then finally are licensed. Only after being licensed are you the responsible party. Until then, everything you do is checked by the "other" pharmacist. every conversation is overheard and every dot and tittle is checked off by someone else. I got my license auth via phone oh-so-many years ago, and that very moment the pharmacist on duty announced " I am going home, enjoy the day". I was absolutely terrified. Its a totally different feeling having that safety net yanked out from underneath you. I totally relate...

I know, I know. From the PT. POV -- My first child was due in June. Naturally, she waited. And waited. I knew what July 1 meant in the teaching hospital where my HMO said I was to deliver (or else!) Needless to say, I went into labor July 3. When the attending asked if "Dr. so and who" could assist, I peered over my legs. Tere was someone no older (in fact younger) than I.Still, (amazing what contractions will do to you) I choked out a "yes" and she did the delivery. Daughter had a 9 Apgar, and she's been a joy so all went well.

When I had to take my final practical exam in medicine, I was sent to take the history from and do an exam on an elderly woman in a 4 bedded room. I went back to my examiners and presented the case. As my report progressed, there were increasingly confused then disgusted looks on their faces. It turned out that I had examined the wrong woman (she had responded to someone else's name). They told me that they could have flunked me for not having checked her wrist band (no chart review was allowed, obviously). What a lesson that was.

PC--when I got my license auth (in the middle of the work day), the PIC STILL wouldn't let me verify or do anything on my own! She said "you're not really licensed until Corporate says you are." Well, two hours later Corporate changed my schedule for the next day, and I was going to close the store, as a float pharmacist. I told myself "at least I'll have someone experienced with me until 8pm." Nope. One of my classmates, who also was licensed the day before. Unfortunately, I look younger than I really am, so when I was counseling a patient he asked, "How long have you been licensed? A day?" Yep.

I've worked in the teaching hospital world for 25 years and understand on an intellectual level how important it is for residents to work on patients and that generally speaking, there is back-up and they know to ask questions. We're a smaller community so the residents I work with on a daily basis I also see in the community and in other medical settings.

Still...when the opportunity came up to schedule something on July 5 or June 1, I picked June 5. I didn't want to be somebody's first! In my mind, the June 1 guys were basically grizzled old warriors by that time. (Although for all I know it could have been a mid-year's first rotation through that service.)

I, too, prefer it when a doctor lets me know that he doesn't know everything. Especially in specialties like psychiatry which are really very inexact sciences. It used to frustrate me when I asked my psychiatrist if something would/wouldn't work and he'd just shrug and say "well, let's try it and see." But now I know that he was giving me the most honest answer that he could give.

As a Critical Care/ ED nurse, my feelings about July are the same as yours ... I hope you don't kill someone, too, and I will be extra vigilant to make sure that doesn't happen. Be nice to the nurses and they will help you every step of the way. Tricia

As a nurse we have that love/hate relationship with Doc's and can be kind of hard on them. Yes it's July and we're getting our new group of "baby doc's" coming. But your story just reminded me of one thing, as much as sometimes we hate to admit it Doc's are people too. I remember my first day when I walked into a patients room and said "Hi I'm going to be your nurse tonight" it was terrifying. I can only imagine what a Doc goes through knowing how much more responsibility is on your shoulders.

I always like getting newly minted doctors. They're less set in their ways, often more open to newer ideas (and by that I don't mean pseudoscience and woo, but newer things in evidence based medicine), more likely to admit when they're wrong or don't know something, and less likely to be stuck in "everyone knows" pseudo-medicine.

I remember my first day too, July 1 in 1994. A co-resident and I started our own practice from scratch, so there wasn't even anyone with more experience down the hall to ask advice from. It's peculiar to feel elated and absolutely terrified at the same time. Fortunately it started light - two office patients (a stable seizure patient and a tremor patient) and one hospital patient (an obvious stroke) - or I likely would have been a gibbering idiot by July 4th. But the hard cases did come, and I still often feeling uncomfortable when there is no clear diagnosis...

I know that even experienced neuros don't have all the answers for neuropathies and that the treatments can require some guesswork and are not always (not often?) successful. I imagine that neuro patients as a group tend to be less satisfied than most, hence more difficult. Perhaps that explains the sense of humor neuros tend to have.

I'm a nurse, and a group of about eight new nurses started the same night (July 1st!) as our new residency class. I remember the conversations we had that night:

Doctor: "Hi! ... How long have you been a nurse?"Me: "It's my first day!"Doctor: "Hey, it's my first day as a doctor!"Me: "Right on! We'll go drink after work, 'kay?"Doctor: "YES."

Eight brand new nurses and ten new doctors = a lot of fun. I missed those guys when they graduated. We learned a lot together, and I always have an incredible amount of empathy for the new physicians coming through. I still take extra good care of them when needed, just remembering how terrified we all were that night of 7/1, fourteen years ago.

Welcome to my whining!

This blog is entirely for entertainment purposes. All posts about patients may be fictional, or be my experience, or were submitted by a reader, or any combination of the above. Factual statements may or may not be accurate.

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